GW1-2023-01499_Well Construction - GW1_20230209

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WELL MMSTRttCTION RECORD (O-11 For hftmal Use On ly
1.Wall cooracter wormWen:
O V1 p b l t4.WATER ZONES
nm TO PROEM
Well Coanaetor NLa�no
n, 2.
NC Well Couttsetor CcrtiEcation Number 60
I U IS.O ter
p ,r. �. KNM �
IS.PmR cASM fll1'fUIBING tEe dosed4owl
2,Well Construction Perndt#: ]MObf To DIA E+Tssi TSr Tut L41
List all applicable well cownvctimpe-Us 6.e.VIC,Coampt State,Yarl mct.dC.) ft, ft la.
3.Well Use(check well use):
Water Supply Well: 17..SCREEN
tOROH TO I3I:AYETER I SLOTSIZE 1 TMCKNM I NUTERIAL.
Agricultural Mumcipamblic q, ft. eta,
Geothermal(Heating/Cooling Supply) QRwidentlal Water Supply(single)
ka.
ladustrial/Conunercial ORcaldcutial Water Supply(sbanw) IL GROUT --
irriation FROM i TOs_ NMOD A AMOUNT
Non-Waiter Supply Well: 0 . Q• G
E]Mcaftoring Oltecovn g, it.
Inject!"Well:
Aquffer Recharge E]Gromwate r Remediation R, ft.
fe Storage and Recovery �ySalini 13arrier t9•SANDiCAAV PAC W
'�4� B ery D tY A rAt. EM1tPi ACBMEN S OU
Aquifer Test 13Stormwater Drainage n• it.
xpexinamtaI Technology 13Subside[ce Control tt. R. r
Geothecnnl(Closed Loop) Tracer 20. GLOG if
Gwdie:mal Rd= Other n under#21 Remardta FROM To ate
4.nntte wen(y Complestedt ` °`�q34 Well ID# p 0 IL
9n
Sa.Well Location. 0 R' b 6 rc Irani (,
1(jt")CL+ey- CL f n.
Facility/OwnerNaam o 'Fac—ility�M#(iNWlkablo) ft �
75 Pla�ll oL� S e-`IL . ltk wlb0 Nc-"d--759 n.
PhyslW Asa,City,and 4 'I
Coutdy Parcel Idcraificatiou No.(PIN)
Sb.Latitude and longitude to degreeshminutaheconds or tleeimal degrees:
(ifwell field,one fat/long is sufficient) 22.Certification:
N WIcYb4-
6.
Is(are)the weil(s)OPermanent or [3Temporary Signature of Certified well Contractor pate
By signing this form,I Aereby terrify drat u uvll(s)weer(rare)cont&rcied in awwzmlce
7.Is this a repair to an existing well: Oyes or o with 15A NCAC 02C.0100 or I JA NCAC(2C.0200 FW1 Construction Sta)dard:and that a
hrikis is a srpetr,fill out knaun well construction hijbrMarion and explain the nature of the copy of this record kw been provided to the well owner.
repair ender i121 remarks section or on the back of this faun.
23.Site diagram or additional well detain:
8.Far Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed Indicate TOTAL NU)MR of wells consknaron detafls. You may also a niche additional pages if necessary.
drilled:__I___
3 G o �U13M1T-I�AL nvsxRVCTlolvla
9.Total well depth below land surface: (fL) 24a, For All Was Submit this ft-rin within 30 days of completion of well
For multiple wells list all depths if dWWvnt(example-3@200'and 2®100� construction to the following:
10.Static water level below top of casing. (ft.) Division of Water Resources,Information Processing Unit,
ff"ater letitd is above casing,use"+� 1617 Mail Service Center,Raleigh,NC 27699-1617
11.13orehole diameter- (ter,)
24
�I b,For Infection War In addition to sending the form to the address in 2Aa
12.Well construction method: "1 t r ( � Q r� above, also submit one copy of this films within 30 days of completion of well
(Le,auger,rotary,cable,direct paste,etc.) "' construction to the following:
FOR WATER SUPPLY WELLS ONLY: DMdou of Water Resources,Underground Injection Con"Program,
6 bUl 1636 Mall Service Centex,Raleigh,NC 17699-16M
13a.Yfe9d(gpm) �Q Method of tat: 24c.For Wa�r Irraly ,[I� ton 1�!gt,]g: ra addition to sending the form to
I the addmss(es) abtrve, also submit oche copy of this form within 30 days of
I3h_IHatatEctloa type:,__ h h Atnoussp b, completion of well construcdon to the county health department of the comity